NIH Press Release
National Institute of Nursing Research

Tuesday, February 16, 1999
4:00 p.m. EST

Contact: Linda Cook, NINR
(301) 496-0209
Susan Greenbaum, UPenn
(215) 898-5074

Transitional Care from Hospital to Home
Improves the Health of Elderly Medical and Surgical Patients

Costs to the Health Care System Lowered

Older people with common medical and surgical problems, who were discharged from the hospital following treatment, realized a significant improvement in their health at reduced costs to the health care system, according to research published in the February 17 issue of the Journal of the American Medical Association. The study, "Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders", tested a model of transitional care. It was led by Mary Naylor, PhD, RN, FAAN, of the University of Pennsylvania's School of Nursing and supported by the National Institute of Nursing Research, NIH.

"This research addresses an important area of compelling need for scientifically-tested interventions," said Patricia A. Grady, PhD, RN, FAAN, Director of the NINR. "The study focuses on a high risk group of older Americans who are living with chronic illness. Since the elderly in our society are living longer and their numbers are expected to increase significantly, health care professionals need feasible strategies, such as the transitional care model, to help patients live healthy, independent lives for as long as possible," she said.

The model uses a multidisciplinary team and involves comprehensive discharge planning, including determination of patient care needs outside the hospital, and follow-up in the home by advanced practice nurses specializing in geriatrics. Findings revealed that six months after discharge, only 20% of the intervention group was rehospitalized, compared to 37% of controls; and only 6.2% had multiple hospital readmissions versus 14.5% for controls. Per-patient days in the hospital were fewer for the intervention group -- 1.53 versus 4.09 for controls, and the costs of post-discharge health services were about $600,000 lower.

"Many patients in the study were coping with an average of five active physical and emotional problems," said Dr. Naylor. "When one considers the number of frail older people hospitalized each year with similar conditions, the potential benefits to the patient and savings to the health care system can be tremendous."

A randomized sample of 363 patients over 65 years of age were assigned to either the group receiving transitional care or a control group that received routine care. Patients in the transitional care group were visited by advanced practice nurses within 48 hours of hospital admission and received home visits up to four weeks post discharge. The same nurse who prepared the patient for discharge also provided the home follow-up. The nurses were available for daily consultation by telephone and coordinated care with other members of the health care team. Patients received comprehensive care that included clinical assessment, monitoring, management of symptoms, caregiver education and assistance, and information related to maintaining health.

According to Dr. Naylor, "The transitional care model is in sharp contrast with current practice, which leaves most patients, once discharged, on their own to obtain necessary follow-up care." In other NINR-supported studies, the model has been tested with highly favorable results in patient populations ranging from pregnant women with diabetes to women undergoing hysterectomies. Dr. Naylor is continuing her research on the transitional care model for patients with heart failure, who did not fare as well in her study. This group will be followed for one year after hospital discharge. Dr. Naylor explained that "It is difficult for patients and their caregivers to manage heart failure symptoms, and patients often have trouble changing certain risky behaviors that contribute to poor general health. The good news is that past studies indicate that between one-third and one-half of hospitalizations for heart failure are preventable."

To obtain further information on NINR's research activities, call the NINR Information Office at (301) 496-0207. NINR press releases, fact sheets and other materials are available on the Internet at